Medical practices providing in-person patient care during the pandemic face a complex infection control environment with evolving guidance from federal and local health authorities. CDC guidance addresses COVID-19 infection control, exposures, and potential shortages of both personnel and protective equipment.
The Maryland Occupational Safety and Health Administration (MOSH) has shared its most frequently asked questions on infection control during COVID-19 with MCMS, and answered our most asked member questions on infection control for this article. MOSH is offering complimentary, 30-minute appointments with their Health Consultants to support medical practices during the pandemic. You can request a consultation by submitting this form.
Q: What guidance is available for infection control in outpatient medical settings?
A: The CDC continues to update guidance titled “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic”. Section one of this resource provides recommendations for routine infection prevention and control (IPC) practices during the COVID-19 pandemic. Medical practice’s policies and procedures should comply with these recommendations, and they should be revisited regularly and updated as changes are published. Guidance changes, with the associated date, are highlighted in a light blue box at the top of CDC guidance. The most recent update to this guidance at the time of this FAQ is November 4, 2020.
Q: A healthcare provider in our facility worked while infected with COVID-19. The provider wore a facemask at all times while interacting with patients. Are patients at risk, and should they be notified?
A: Anyone who had prolonged close contact (within 6 feet for at least 15 minutes) should be considered potentially exposed. The use of a facemask for source control and adherence to other recommended infection prevention and control (IPC) measures (e.g., hand hygiene) by the provider help to reduce the risk of transmission or severe illness. In areas with moderate to substantial community transmission, patients are already at risk for exposure to SARS-CoV-2 due to exposures outside their home and should be alert to the development of signs or symptoms consistent with COVID-19.
The following should be considered when determining which patients are at higher risk for transmission and might be prioritized for evaluation and testing:
- Facemask use by the patient – Mirroring the risk assessment guidance for healthcare personnel, patients not wearing a facemask would likely be at higher risk for infection compared to those that were wearing a facemask.
- Type of interaction that occurred between the patient and infected provider – An interaction involving manipulation or prolonged close contact with the patient’s eyes, nose, or mouth (e.g., dental cleaning) likely poses higher risk of transmission to the patient compared to other interactions (e.g., blood pressure check).
- PPE used by infected HCP – HCP wearing a facemask (or respirator) and face shield that extends down below the chin might have had better source control than wearing only a facemask. Note that respirators with exhalation valves might not provide source control.
- Current status of patient – Is the patient currently admitted to a hospital or long-term care facility? These individuals, if infected, can be at higher risk for severe illness and have the potential to expose large numbers of individuals at risk for severe disease.
Q: A healthcare provider in our facility worked while infected with COVID-19. What time period and criteria should we use to determine patients, visitors, and staff who might have been exposed?
A: Anyone who had prolonged close contact (within 6 feet for at least 15 minutes) with the infected healthcare provider might have been exposed.
- If the provider had COVID-19 symptoms, the provider is considered potentially infectious beginning 2 days before symptoms first appeared until the provider meets criteria to discontinue Transmission-Based Precautions or Home Isolation.
- If the provider did not have symptoms, collecting information about when the provider may have been exposed could help inform the period when they were infectious.
- If an exposure is identified. The provider should be considered potentially infectious beginning 2 days after the exposure until criteria to discontinue Transmission-Based Precautions or Home Isolation are met.
- If the date of exposure cannot be determined. For the purposes of contact tracing, it is reasonable to use a cutoff of 2 days before the specimen testing positive for COVID-19 was collected as the starting point, continuing until the criteria to discontinue Transmission-Based Precautions or Home Isolation are met. Although the infectious period is generally accepted to be 10 days after onset of infection, eliciting contacts during the entire 10 days before obtaining the specimen that tested positive for COVID-19 is likely inefficient. In most situations an exposed provider cannot recall all contacts over the preceding 10 days. Also, because recent data suggest that asymptomatic persons may have a lower viral burden at diagnosis than symptomatic persons, the additional resources required may divert case investigation and contact tracing resources away from activities most likely to interrupt ongoing transmission.
Contact tracing is generally recommended for anyone who had prolonged close contact with the person with COVID-19 during these time periods. While this question addresses exposure to a potentially infectious provider, the following actions are also recommended if the potentially infectious individual is a patient or visitor.
Recommended actions for HCP, patients, and visitors:
- Perform a risk assessment and apply work restrictions for other HCP who were exposed to the infected provider based on whether these HCP had prolonged, close contact and what PPE they were wearing. More detailed information is available in the Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19.
- Place exposed patients who are currently admitted to the healthcare facility in appropriate Transmission-Based Precautions and monitor them for onset of COVID-19 until 14 days after their last exposure.
- Perform contact tracing of exposed patients who are not currently admitted to the healthcare facility and for visitors as described in Health Departments: Interim Guidance on Developing a COVID-19 Case Investigation and Contact Tracing Plan.
Healthcare facilities should have a process for notifying the health department about known or suspected cases of COVID-19, and should establish a plan, in consultation with local public health authorities, for how exposures in a healthcare facility will be investigated and how contact tracing will be performed. The plan should address the following:
- Who is responsible for identifying contacts and notifying potentially exposed individuals?
- How will such notifications occur?
- What actions and follow-up are recommended for those who were exposed?
Contact tracing should be carried out in a way that protects the confidentiality of affected individuals to the extent possible and is consistent with applicable laws and regulations. HCP and patients who are currently admitted to the facility or were transferred to another healthcare facility should be prioritized for notification. These groups, if infected, have the potential to expose a large number of individuals at higher risk for severe disease, or in the situation of admitted patients, be at higher risk for severe illness themselves.
Information for health departments about case investigation and contact tracing is available in the Health Departments: Interim Guidance on Developing a COVID-19 Case Investigation and Contact Tracing Plan. This guidance could also be helpful to healthcare facilities performing such activities.
Q: A healthcare provider in our facility has a family member who is positive for COVID-19. Should they be excluded from work and, if so, for how long?
- If HCP are able to quarantine away from the infected individual living with them, they should quarantine at home and not come into work for 14 days following their last exposure to the infected individual.
- If HCP are not able to quarantine away from the infected individual living with them and have ongoing unprotected exposure throughout the duration of the individual’s illness, they should remain in home quarantine and be excluded from work until 14 days after the infected individual meets criteria for discontinuation of home isolation.
- If HCP develop SARS-CoV-2 infection while they are in quarantine, they should be excluded from work until they meet all return to work criteria for HCP with SARS-CoV-2 infection.
Home quarantine and work exclusion of asymptomatic exposed HCP who have recovered from SARS-CoV-2 infection in the prior 3 months might not be necessary. Additional information about this scenario is available here.
Q: What guidance applies to COVID-19 exposures in an outpatient setting?
A: The CDC continues to update guidance titled “Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19”. Medical practice’s policies and procedures should comply with these recommendations, and they should be revisited regularly and updated as changes are published. Guidance changes, with the associated date, are highlighted in a light blue box at the top of CDC guidance.
Q: Should a health care professional within 3 months of their initial infection be preferentially assigned to care for patients with suspected or confirmed COVID-19 infection?
A: While individuals who have recovered from SARS-CoV-2 infection might develop some protective immunity, the duration and extent of such immunity are not known. Staffing decisions should be based on usual facility practices. Any HCP assigned to care for patients with suspected or confirmed SARS-CoV-2 infection, regardless of history of infection, should follow all recommended infection prevention and control practices when providing care. Guidance on mitigating staff shortages is also available.
Q: Do OSHA and CDC guidelines for healthcare and other workers align?
A: Both agencies’ worker-focused guidance is intended to help protect workers from exposure to SARS-CoV-2 spread via respiratory sections, including as a result of exposure to infectious individuals or to exposure to contaminated surfaces.
CDC guidance for some sectors, such as healthcare, reflects the realities of ongoing PPE supply chain shortages. OSHA continues to recommend what it believes are the best methods to protect workers, but is providing enforcement discretion to address those supply chain concerns, as well.
Q: Why does OSHA recommend goggles in addition to airborne precautions?
A: Precautions for SARS-CoV-2 are based on evolving epidemiologic evidence of how the virus spreads, and what is known about transmission from SARS and MERS outbreaks. Airborne precautions, including the use of NIOSH-certified N95 or better respirators, are appropriate because the virus may be spread through a range of respirable particle sizes. Since SARS-CoV-2 may infect people through mucous membranes of the eyes and face, face/eye protection is also needed.
Q: Clinical samples of sputum are not covered by the Blood Borne Pathogens (BBP) standard’s universal precautions. How should employers protect workers handling these samples?
A: While universal precautions do not apply to sputum in the BBP standard, standard precautions that CDC introduced to protect healthcare workers from a wider range of pathogens, do. Follow standard and transmission-based (contact + airborne) precautions. OSHA and CDC infection prevention recommendations are more protective than the minimum precautions the BBP standard requires.
Q: COVID-19 is not a bloodborne pathogen, so does the BBP standard apply?
A: The BBP standard applies to occupational exposure to blood, certain body fluids, and other potentially infectious materials, as defined in the standard. Even though SARS-CoV-2 is a respiratory virus, workers in healthcare and other sectors may still have occupational exposures covered by the standard. In those cases, employers must comply with the provisions of the standard.
Q: Do I have to record cases of COVID-19 on my entity’s OSHA 300, 300A, & 301 forms?
A: OSHA recordkeeping requirements at 29 CFR Part 1904 mandate covered employers record certain work-related injuries and illnesses on their OSHA 300 log. While 29 CFR 1904.5(b)(2)(viii) exempts recording of the common cold and flu, COVID-19 is a recordable illness when a worker is infected on the job. Find additional injury and illness recordkeeping information at OSHA.gov.
Q: Does the CDC’s infection control guidance apply to behavioral health facilities?
A: Yes. To keep patients and healthcare personnel (HCP) healthy and safe, CDC’s infection prevention and control guidance applies to all settings where healthcare is delivered. However, as with any guidance, facilities can tailor certain recommendations to their setting. For example, inpatient psychiatric care includes communal experiences and group activities that may need to continue. If so, these activities might need to be adapted to align with social distancing recommendations. Other recommended infection control measures (for example, ensuring access to alcohol-based hand sanitizer, cohorting patients with COVID-19 and assigning dedicated staff, or implementing universal source control measures) might not be safe or appropriate to implement in all locations or for all patients due to security and behavioral concerns.
Challenges and potential solutions specific to behavioral health settings might include:
- Challenge: To prevent transmission, it is generally recommended that patients with COVID-19 be transferred to a separate area of the facility where they can be cared for by dedicated HCP. Because of security concerns or specialized care needs, it might not be possible to cohort certain patients together or change HCP assigned to their care.
- Potential Solutions: When cohorting is not possible, implement measures to maintain social distancing (at least 6 feet) between patients with COVID-19 and others on the unit. Ideally, this would include a separate bathroom for COVID-19 patients. Ensure HCP wear all recommended personal protective equipment (PPE) when caring for patients with suspected or confirmed COVID-19.
- Group Therapy Sessions
- Challenge: Group counseling, therapy, and discussion sessions are a critical component of psychiatric treatment and care plans, but the traditional set-up for these activities is not compatible with social distancing recommendations.
- Potential Solutions: When possible, use virtual methods, or decrease group size so social distancing can be maintained. In the event that COVID-19 is transmitted in the facility, sessions should stop or move to a video discussion forum until additional infection prevention measures are in place to stop the spread.
- Cloth Face Coverings
- Challenge: For some patients, the use of cloth face coverings or facemasks might pose an additional danger or may cause distress. Some patients may be unable or unwilling to use them as intended. Elastic and cloth straps can be used for strangling oneself or others, and metal nasal bridges can be used for self-harm or as a weapon.
- Potential Solutions: Consider allowing patients at low risk for misuse to wear cloth face coverings or facemasks, with a preference for those with short ear-loops rather than longer ties. Consider use of cloth face coverings or facemasks during supervised group activities. Ensure that HCP interacting with patients who cannot wear a cloth face covering or facemask are wearing eye protection and a facemask (or a respirator if the patient is suspected to have COVID-19 and respirators are available).
- Alcohol-based Hand Sanitizer
- Challenge: While alcohol-based hand sanitizer (ABHS) containing 60-95% alcohol is an important tool to increase adherence to hand hygiene recommendations, ABHS must be used carefully in psychiatric facilities to ensure it is not ingested by patients.
- Potential Solutions: Consider not placing ABHS in patients’ rooms in psychiatric facilities, nor in locations where the patients have unsupervised access. Encourage frequent hand washing with soap and water for patients and HCP. Consider providing personal, pocket-sized ABHS dispensers for HCP.
- Challenge: As part of social distancing, communal dining is generally not recommended. However, eating needs to remain supervised due to the potential for self-harm with eating utensils and because commonly used psychiatric medications may cause side effects (e.g., tardive dyskinesia, dysphagia, hypo- and hypersalivation) that increase choking risk for patients.
- Potential Solutions: One option is to position staff in patients’ rooms to monitor their dining. Another option is to allow communal dining in shifts so that staff can monitor patients while ensuring they remain at least 6 feet apart. A third option is to have patients sit in appropriately spaced chairs in the hallway outside their rooms so they can be monitored while they eat.
- Challenge: A higher proportion of psychiatric patients smoke cigarettes compared to the general population. Patients might congregate in outdoor smoking spaces without practicing appropriate social distancing.
- Potential Solutions: Limit the number of patients allowed to access smoking spaces at the same time, and position staff to observe and ensure patients are practicing appropriate physical distancing.
Q: How long should an exam room remain vacant after being occupied with a patient with confirmed or suspected COVID-19?
A: Although spread of SARS-CoV-2 is believed to be primarily via respiratory droplets, the contribution of small respirable particles to close proximity transmission is currently uncertain. Airborne transmission from person-to-person over long distances is unlikely.
The amount of time that the air inside an examination room remains potentially infectious is not known and may depend on a number of factors including the size of the room, the number of air changes per hour, how long the patient was in the room, if the patient was coughing or sneezing, and if an aerosol-generating procedure was performed. Facilities will need to consider these factors when deciding when the vacated room can be entered by someone who is not wearing PPE.
For a patient who was not coughing or sneezing, did not undergo an aerosol-generating procedure, and occupied the room for a short period of time (e.g., a few minutes), any risk to HCP and subsequent patients likely dissipates over a matter of minutes. However, for a patient who was coughing and remained in the room for a longer period of time or underwent an aerosol-generating procedure, the risk period is likely longer.
For these higher risk scenarios, it is reasonable to apply a similar time period as that used for pathogens spread by the airborne route (e.g., measles, tuberculosis) and to restrict HCP and patients without PPE from entering the room until sufficient time has elapsed for enough air changes to remove potentially infectious particles.
General guidance on clearance rates under differing ventilation conditions is available.
In addition to ensuring sufficient time for enough air changes to remove potentially infectious particles, HCP should clean and disinfect environmental surfaces and shared equipment before the room is used for another patient.
Q: Where can I find detailed information on cleaning and disinfection?
A: For more information see CDC guidelines for healthcare facilities that cover cleaning, disinfection, sterilization, and hand hygiene:
- Guideline for Environmental Infection Control, 2003
- Guideline for Disinfection and Sterilization, 2008
- Guideline for Hand Hygiene in Healthcare Settings
Q: Are there ways to audit cleaning processes?
A: Cleaning guidelines vary based on devices and surfaces being cleaned. Multiple methods are used to measure the residual bioburden or effectiveness of cleaning (e.g., ATP, fluorescent markers, blood, protein, carbohydrate, and RODACTM plates, or touch plates). See the CDC Environmental Toolkit for additional information on developing a cleaning evaluation program.
Resources & Further Reading:
CDC COVID-19 Infection Control Guidance
- Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic
- Using Personal Protective Equipment (PPE)
- Hand Hygiene Recommendations
- Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19
- Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance)
- Optimizing Personal Protective Equipment (PPE) Supplies
- Clinical Questions about COVID-19: Questions and Answers
- COVID-19 Surge Tool
- Strategies to Mitigate Healthcare Personnel Staffing Shortages
American College of Medical Toxicology